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EHR Metadata Could Enhance Clinical Decision Support Alerts

Leveraging EHR metadata, including audit and access logs, could help develop and refine clinical decision support alerts for providers.

March 07, 2019 - Using EHR metadata, such as audit data and access log details, may help optimize the design and development of provider clinical decision support (CDS) and EHR-based alerts, a study published in JMIR Medical Informatics revealed.

While audit and access logs in the EHR are mainly used for security purposes, the researchers noted that this information can also be used to answer important research and clinical questions.

“Access logs contain time-stamped recordings of who accessed the EHR and what part was accessed. Audit logs record chronological activity in the EHR, tracking actions such as what data were created, reviewed, or changed by the user,” the team wrote.

“These log data, though potentially complex to retrieve and interpret, can be used by researchers and care teams to identify targets for clinical interventions as well as care quality and safety-improvement efforts.”

Researchers set out to use access and audit log data to better understand how non-interruptive EHR alerts impact physician behavior. Unlike alerts that pop up and interrupt workflow, non-interruptive alerts deliver information to an EHR in-basket, requiring the user to open and review them.

The team examined 799 alerts sent to 75 primary care physicians (PCPs). The alerts corresponded to 713 patients.

Of the 799 alerts, 78.5 percent were opened by the addressed PCP. Researchers tracked subsequent actions for 616 of these PCP-addressed alerts, and found that 208 (33.8 percent) resulted in a PCP immediately viewing the patient’s EHR.

Of all 799 alerts, 538 (67.3 percent) were followed by PCP actions either that day or the next day.

Researchers also categorized the alerts into three separate groups: those containing information about new and high-risk medications at the time of hospital discharge (“information only”), those containing recommendations to cancel or modify medication doses (“medication recommendation”), and those containing recommendations for tests (“test recommendation”).

Of the 445 information-only alerts, 28.1 percent were followed by an immediate viewing of a patient’s EHR. Fifty-four percent of medication recommendation alerts and 47.1 percent of the test-recommendation alerts also triggered an EHR review.

Among information-only alerts, 64.4 percent were followed by a general action in the EHR. Nearly 80 percent of medication recommendation alerts and 75.1 percent of test recommendation alerts were also followed by a general action in the EHR, showing that PCPs were significantly more likely respond to medication- or test-specific alerts than information-only alerts.

In the five minutes after opening the alerts, those PCPs that immediately viewed a patient’s EHR spent an average of 106 seconds looking at the patient’s record. Those PCPs who didn’t immediately view a patient’s EHR kept the alert on their screen for an average of 26 seconds.

“Data from access and audit logs provide a rare ‘behind-the-scenes’ glimpse into how healthcare team members spend their time and where they direct their attention,” the researchers said.

“EHR logs can also provide valuable implementation data that can be used to improve future CDS interventions. Log data can help a research team understand whether a CDS message was opened by the addressed recipient, how long it was viewed for, and what kind of actions followed the viewing.”

Audit and access logs have previously been used to better understand a healthcare team’s communication, workflow, and trainee skill, the researchers said, and these data can help modify alerts to better suit providers’ needs.

“Understanding who opens these messages lends insight into a care team’s triage processes, which might alter the design of the intervention (eg, physician-directed CDS sent to a team where all messages are opened initially by nurses might prompt the team to modify message content or change the method of communication),” the team wrote.

“Additionally, realizing that providers spend an extremely short period of time with alerts open might prompt those designing these alerts to adapt messages accordingly (eg, include fewer words and optimize visibility of key text).”

The study was limited in that the team didn’t examine any actions outside of the EHR, which means they may have missed some PCP actions after opening the alerts. Researchers also said that future studies could evaluate providers’ own perspectives on their actions after opening alerts.

The findings from this study demonstrate the potential for access and audit logs to inform the development of CDS alerts and improve patient care.

“The availability of information in the EHR can benefit similar studies trying to understand the link between provider behavior in the EHR and patient care and outcomes,” the researchers concluded.

“Data from these logs can provide researchers with insight into designing impactful EHR–based CDS and alert interventions.”